6009 Beltline Rd, Ste. 100, Dallas, TX 75254 Tel 972-239-1998 • Fax 972-239-8899 www.PrestonwoodDental.com

Shweta G. Daftary, DDS

Patient Information (Confidential) Today’s Date ___________

Name _____________________________________________________________ Birthdate _________________ SS# ______________________

Address _________________________________________________________________ City _______________ State Zip _________

Home Phone ________________________________________________ Work Phone _________________________________________________

Cell Phone __________________________________________________ E-mail ______________________________________________________

Employer ___________________________________________________________________________ Work Phone ________________________

Business Address ___________________________________________________ City ______________________ State Zip _______

Spouse/Parent’s Name _______________________________________________ Employer _________________ Work Phone _______________

If Student, Name of School/College __________________________ City ____________________ State Full Time Part Time

Person to Contact in Case of Emergency _____________________________________________________________________________________

Relationship to Patient ________________________________________ Phone ______________________________________________________

Whom Shall We Thank For Your Referral ____________________________________________________________________________________

Appointment Reminder via Email Phone call SMS/Text Message (Phone Carrier) ___________________________________

Responsible PartyName of Person responsible Relationshipfor this Account ________________________________________________________________ to Patient ________________________________

Address ______________________________________________________________________ Phone ___________________________________

Employer _____________________________________________________________________ Phone ___________________________________

Driver’s License# ______________________________ Birthdate ____________________________ SS# _________________________________

Insurance Information (All about insured)

Name of Insured _______________________________________________________________ Relationship to Patient _____________________

Birthdate _____________________________________ SS# _________________________________ Phone _______________________________

Insurance Company ____________________________________________________________ Phone ___________________________________

Name of Employer ______________________________________________________________ Phone __________________________________

Smile Analysis Ask Dr. Daftary how you can transform your smile from dull to dazzling!

Yes No Yes No

Do you feel that your teeth are too small or too large? Are there spaces between your teeth?

Have your gums receded? Do your teeth slant one way or another?

Do you show too much gum tissue when you smile? Are your teeth dull, dark, or stained?

Are you unhappy with any crowns in your mouth? Are any of your teeth missing?

Are your teeth crooked, mis-shapen, or out of line? Are any of your teeth that have old fillings, stained blue or gray?

Are the biting edges of your teeth worn down?

6009 Beltline Rd, Ste. 100, Dallas, TX 75254 Tel 972-239-1998 • Fax 972-239-8899 www.PrestonwoodDental.com

Patient Medical HistoryPhysician ____________________________________________________________________________ Office Phone _______________________

Are you currently under any medical treatment? If yes, please explain ______________________________________________________________

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Have you ever been hospitalized for any surgical treatment or illness in the past 5 years? _____________________________________________

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Are you currently taking any medications, including over the counter medications? Please list all _______________________________________

_________________________________________________________________________________________________________________________Do you have or have you had any of the following? Please check all that apply.

Asthma ..................................................... Glaucoma ................................................. Rheumatic Fever ......................................AIDS or HIV infection ................................ High blood pressure ................................. Radiation Therapy .....................................Anemia ..................................................... Heart Murmur ........................................... Recent weight loss ....................................Angina ...................................................... Heart Disease/Heart Attack ...................... Stroke .......................................................Artificial Heart Valve .................................. Hepatitis/Jaundice .................................... Stomach troubles/Ulcers ...........................Arthritis ..................................................... Joint Replacements/Implants .................... Sexually Transmitted Diseases ..................Cardiac pacemaker .................................. Kidney Diseases ....................................... Tuberculosis ..............................................Cancer ..................................................... Liver Diseases .......................................... Thyroid Problems ......................................Diabetes ................................................... Low blood pressure .................................. For Women:Epilepsy .................................................... Leukemia .................................................. Are you pregnant? .....................................Emphysema ............................................. Mitral Valve Prolapse ................................. Due date ____________________________Fainting/ Seizures ..................................... Respiratory Problems ............................... Are you Nursing? ......................................

Others ___________________________________________________________________________________________________________________

Allergies to any medications _____________________________________________________________________________________________

Patient Dental HistoryName of Previous Dentist and Location ___________________________________________________ Date of Last Exam _________________

Yes No Yes No1. Do your gums bleed while brushing or flossing? 8. Do you have frequent headaches?

2. Are your teeth sensitive to hot or cold liquids/foods? 9. Do you clench or grind your teeth?

3. Are your teeth sensitive to sweet or sour liquids/foods? 10. Do you bite your lips or cheeks frequently

4. Do you feel pain in any of your teeth? 11. Have you ever had any difficult extractions or prolonged bleeding from it in the past?

5. Do you have any sore or lumps in or near your mouth?

6. Have you had any head, neck or jaw injuries? 12. Have you had any orthodontic treatment?

7. Have you ever experienced any clicking or pain in the TMJ area, difficulty in opening or closing of your jaw?

13. Do you wear dentures or partial?

If yes, date of placement _________________

Authorization and Release• I certify that I have read and understood the above information to the best of my knowledge. The above questions have been accurately answered.

I understand that providing incorrect information can be dangerous to my health. If I have any changes in my health, I will inform Dr. Daftary at my next appointment.

• I authorize Dr. Daftary and her staff to take x-rays, models, photos and/or other diagnostic aids necessary for a thorough oral diagnosis of myself and/or my minor dependent listed on this form.

• I also authorize Dr. Daftary to release any such information to third party payors and/or healthcare practitioners for the purpose of rendering treatment, payment activities and healthcare operations.

• I understand and acknowledge that Dr. Daftary may use my photographs in her marketing campaign for educational purposes to potential patients.• I understand that my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services

rendered on my behalf or my dependents.•

Signature of patient/parent of minor ________________________________________________________ Date ________________________

Medical Update (for office use only) ______________________________________________________________________________________________

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Shweta G. Daftary, DDS